Cerebral palsy (CP) is an umbrella term where an injury to the immature brain affects muscle tone and motor control, posture, and at times, the ability to walk and stand. Orthoses can be used to improve or maintain function. Ankle-foot orthoses (AFOs) are the most frequently used orthoses in children with CP. However, how commonly AFOs are used by children and adolescents with CP is still unknown. The aims of this study were to investigate and describe the use of AFOs in children with CP in Sweden, Norway, Finland, Iceland, Scotland, and Denmark, and compare AFO use between countries and by gross motor function classification system (GMFCS) level, CP subtype, sex, and age.Aggregated data on 8,928 participants in the national follow-up programs for CP for the respective countries were used. Finland does not have a national follow-up program for individuals with CP and therefore a study cohort was used instead. Use of AFOs were presented as percentages. Logistic regression models were used to compare the use of AFOs among countries adjusted for age, CP subtype, GMFCS level, and sex.The proportion of AFO use was highest in Scotland  and lowest in Denmark . After adjusting for GMFCS level, children in Denmark, Finland, and Iceland had statistically significantly lower odds of using AFOs whereas children in Norway and Scotland reported statistically significantly higher usage than Sweden.In this study, the use of AFOs in children with CP in countries with relatively similar healthcare systems, differed between countries, age, GMFCS level, and CP subtype. This indicates a lack of consensus as to which individuals benefit from using AFOs. Our findings present an important baseline for the future research and development of practical guidelines in terms of who stands to benefit from using AFOs.The online version contains supplementary material available at 10.1186/s12891-023-06554-z. Cerebral palsy (CP) is an umbrella term where an injury to the immature brain affects muscle tone and motor control, and oftentimes also posture and ability to walk and stand . In seveOrthoses, often in combination with other treatments, are used to improve or maintain function. Orthoses might enable activity and participation by facilitating movement, providing stabilization, and to lesser extent reducing pain in children with CP , 5. In SAnkle-foot orthoses (AFO) are the most frequently used orthoses in children with CP –8. In SwIn this study, we described the use of AFOs in children with CP in Sweden, Norway, Finland, Iceland, Scotland, and Denmark, and compared AFO use by country, gross motor function, CP subtype, sex, and birth year.This study was based on cross-sectional register data from children ages 0–18 years included in the follow-up program and national register for individuals with CP in each participating country, Sweden (CPUP); Norway (NorCP); Iceland (CPEF); Scotland (CPIPS); and Denmark (CPOP) . With thhttps://www.arcada.fi/en/research/key-research-activities/cp-north) [Due to the national regulations in some of the countries included, we were not permitted to share individual data across borders. Therefore, data from the latest PT assessments performed in 2017 or 2018 were de-identified and aggregated in each country and compiled per birth year, by CP subtype, sex, gross motor function, and the use of AFOs for all children born between 2000 and 2018 in the register/cohort. Based on the assessment schedules, the participants are assessed once or twice per year or every other year (depending on age and level of gross motor function) by PTs and OTs  and datap-north) .AFO included all types of orthoses that start below the knees, end on the feet, and provide direct control over the foot and ankle joints. Use of AFOs was dichotomized (yes/no). Birth years were categorized into three groups: 2000–2005, 2006–2011, and 2012–2018. Gross motor function was classified according to the Gross Motor Function Classification System (GMFCS) levels (I-V or not classified). GMFCS level I indicates the highest gross motor function and level V the lowest . CP subtThe use of AFOs was presented as percentages (%) and the raw numbers of the denominators (n) were presented by country, birth year group, GMFCS level, CP subtype, and sex. Linearity of the participants’ AFO use by birth year was first inspected through a bar chart of merged data from all countries birth year data. Because there was a peak in AFO use for children born 2006–2011, the decision was made to categorize the participants into three birth year groups. Logistic regression was used to compare the use of orthoses (yes/no) among countries adjusted for birth year group, GMFCS level, CP subtype, and sex. In the regression analysis, data were included only for those children who had subtypes and GMFCS level recorded. Sweden, with the most participants, was set as the reference country.p < 0.05. Given the small sample from Iceland (N = 70), logistic regressions were performed with and without the Icelandic data included. However, the results were similar, and therefore the findings were presented with the Icelandic data included. SPSS v27 was used for all analyses.As the data were aggregated, it was not possible to adjust for sex, CP subtype, and GMFCS level in the same model. Instead, one model that included only country and birth year group, which were available for all participants was used. Subsequently, we adjusted for CP subtype, GMFCS level, and sex in three logistic regressions with AFO use as the dependent variable with 95% confidence intervals (CI) and level of statistical significance set to The proportion of children reported to use AFOs was highest in Scotland with 57% of 1,955 children and lowest in Denmark with 35% of 1,196  of the boys and 31% (10/32) of the girls were reported to use AFOs. In Finland, 44% (115/262) of the boys used AFOs compared to 43% (87/203) of the girls.The use of AFOs differed statistically significantly by country Table . The difDenmark and Finland had statistically significantly lower AFO use ORs in all four models (Denmark range of OR 0.43–0.50 and Finland range of OR 0.68–0.74) than Sweden. In Iceland, the ORs were lower for AFO use than Sweden but this was only statistically significant when adjusting for CP subtype (OR 0.52 CI 0.31–0.86) and GMFCS level (OR 0.58 CI 0.35–0.95). Differences in AFO use between the sexes were close to statistically significant  with higher odds of using AFOs for the girls (OR 1.09 CI 1.00-1.18).In this study, we investigated the prevalence of AFO use in Sweden, Norway, Iceland, Finland, Scotland, and Denmark by birth year group, CP subtype, GMFS level, and sex. Despite having similar healthcare systems and follow-up programs for children with CP, the reported use of AFOs differed substantially among the countries, even after controlling for birth year, CP subtype, GMFCS level, and sex. The results may reflect the heterogeneity of the study population and the subjective decision of when and to whom AFOs should be prescribed. The findings could also be explained by country-specific preferences and traditions in terms of who is believed to benefit from using AFOs. To explain the reasons for the observed differences, more research is needed. The use of AFOs in Sweden has been studied previously by Wingstrand et al. in 2014  and our Prescribing orthoses to children with CP when they may not actually be beneficial to the child is probably not harmful or detrimental to their musculoskeletal care. However, it might restrict the child in terms of participation and carrying out certain physical activities. For example, a child with AFOs might have better stability in standing but may not be able to put on his/her shoes without assistance, which might infringe on their independence. In Firouzeh et al’s review in 2019 they describe the lack of evaluating AFOs in participation and activity outcomes which is important given that more than every second child with CP use AFOs in some countries. Anti et al. suggested already in 2006 that daily routine and floor mobility in small children might be challenged by AFO use , 26. ThiOwen (2020) discusses the importance of goalsetting in terms of activity and participation in addition to biomechanical control , and howThe GMFCS level was the strongest predictor in terms of estimating AFO use in children and adolescents with CP and data on GMFCS level were recorded for almost every child in the study . The GMFCS level associated with the greatest proportion of AFO use, differed among the countries, however. For instance, in Sweden and Norway, individuals at GMFCS level IV were more likely to report AFO use, compared to individuals at GMFCS level III in Finland, Iceland, Scotland, and Denmark. The fact that there were no statistically significant differences between the proportions of AFO use by sex is encouraging given that there are no apparent reasons as to why the use of AFOs should differ between boys and girls.The predictive value determined by Nagelkerke R was low overall (< 16), indicating that CP subtype and GMFCS level are not strong factors in terms of predicting which children with CP will use AFOs, although both are important factors in the prescribing process. This highlights the need for clearer evidence-based guidelines to help providers and families decide who should be prescribed AFOs. If the work on when to use lower extremity orthoses begun by Owen  is develThe fact that we had to use aggregated data affects the ability to adjust for country, gross motor function, CP subtype, sex, and birth year group in the same model, which might have given us a more precise view of who is the most typical AFO user. Although not included as an aim, it would still have been helpful to have had more information available regarding if and when a child might have used AFOs in the past. Despite this study being population-based in Scotland, Norway, Denmark, and Sweden, the small, perhaps not representative, number of participants in Iceland and Finland might limit the generalizability. In addition to this, a small number of individuals from Iceland were included, which means that the data from a few individuals had a large impact on the group percentages. However, this also reflects the small overall population of Iceland. Furthermore, given that the CP subtype is not always determined before the child’s fourth birthday, the subtypes for the children under five years of age should be interpreted with caution. In addition, Sweden had a large percentage of missing diagnoses of CP subtype (38%), which has been an ongoing problem due to lack of neuropediatricians. This is currently being remedied and future studies including Swedish CPUP data should have less missing data on CP subtype. Finally, some children with suspected but not diagnosed CP might have been included in the study given that also children younger than 4–5 years of age, the age when a diagnosis of CP is generally made, were included. However, we know from many years’ experience that most young children included in the follow-up program do eventually get a diagnosis of CP.This study contributes to our understanding of the use of AFOs in children with CP in Northern Europe, where AFOs are provided free of charge at the point of use. We found that the AFO use in children with CP in countries with similar healthcare systems, differed between countries, age, level of gross motor function, and CP subtype. Our findings present a baseline for the future research development of practical guidelines in terms of who stands to benefit from using AFOs.Below is the link to the electronic supplementary material.Supplementary Material 1


The suspension of the penis is provided by two ligaments: fundiform and suspensory. These ligaments are sectioned during some augmentative surgical procedures. The structure, the relations and the variability of these ligaments have been demonstrated. The penile neurovascular bundle and its relationships have also been emphasized. A clear knowledge of these details should ensure a reduction of the risk of surgical injury during augmentation procedures.We dissected the ligaments providing the suspension of the penis in 7 formalized corpses. We identified, for each of the ligaments, the origin, the insertion and the relations. The dissection pieces were photographed and the images obtained were discussed upon. We described the variability of the anatomical distribution and highlighted the relations with the vascular and nervous structures for each of these ligaments. The anatomical variability of the fascia and the relations with the base of the penis were also emphasized. For the suspensory ligament, we identified three groups of fibers through which it is attached to the penile body.The dissections were conducted in layers, corresponding to the operative steps for the penile augmentation procedures. We believe that our study highlights the anatomical basis necessary to safely perform these surgeries. The study contributes to the description of the anatomical variability of the ligaments and logically presents details that contribute to preventing most surgical incidents. There are two ligaments that contribute to the maintaining of the physiological prepubic curvature of the penis: a superficial one, known as the fundiform ligament, and a deeper one, known as the suspensory ligament . These lIn the context of a considerable amount of social pressure that links sexual performance to the size of the penis, penile lengthening surgeries have been proposed to men with true congenital microphallus, which is defined as a penis with normal anatomy, but with a size less than 2.5 SD below the normal population  or condiLittara et al.  stated tThe surgical lengthening technique mainly involves an inverted "V–Y" penopubic skin advancement , with idThe procedure might require the addition of a silicone spacer placed between the penis and the pubis, mainly to prevent the ligaments from reattaching . The surIn the literature, however, we have encountered terminology that can often be confusing. For example, in “Traité d'Anatomie humaine—par L. Testut” only the suspensory ligament is described, while other publications such as “Gray's Anatomy – The Anatomical Basis of Clinical Practice 41st Edition” do not mention the fundiform ligament. In other articles, the term fascia Scarpa is used to describe the fundiform ligament , 15. On In this study, we aim to identify these ligaments by dissection, to describe the important vascular and nervous relations and to demonstrate the distribution of the different structural bundles.The dissections were performed on seven cadavers in the laboratory of the Anatomy Department of the “Carol Davila” University of Medicine and Pharmacy.The cadavers have been previously formalized by injection into the femoral artery with a 10% formalin solution and then kept for 30 days in tanks containing the same concentration of formalin.The dissections were performed in anatomical layers. The fundiform and suspensory ligaments were identified and the origin, insertion, dimensions and relations with the penile sheaths were described. The dissection pieces were photographed and discussed upon. The images have been digitally edited without altering the scientific content.To identify the fundiform ligament, we sectioned and then removed the skin and the superficial abdominal fascia.A unique triangular structure;A double structure accompanied by accessory fascicles;A ligament structure with the aspect of an undifferentiated fibrous connective band.We have identified three types of fundiform ligament:In four cadavers, the fundiform ligament was identified in the form of a unique triangular-looking fibrous structure, with the superior angle attached to the abdominal linea alba. Its length was between 5–7 cm, measured from the dorsal aspect of the penis to the apex of the ligament. Its width at the base is between 2–3 cm.Figure In the upper part, the deep aspect of the ligament is attached to the abdominal linea alba. The ligament descends anteriorly from the pubic symphysis. The insertion allows a relatively easy separation of the ligament from the white line and its isolation by surgical dissection. Some of the fibers of the suspensory ligament are attached to the superficial fascia of the penis, while others surround the penile body. This arrangement explains the formation of the prepubic curvature of the penis. Sometimes this attachment can have a lower placement .In one cadaver, we identified a fundiform ligament with a complex appearance. See Fig. Figure This double structure must be taken into account when the surgeon intends to section the fundiform ligament. It is obvious that there may be a risk of sectioning a single ligament component. As can be seen in Fig. The additional lateral ligament bundles were detached and folded down in the next step of the dissection of the cadaver depicted in Fig. The third variant of fundiform ligament is presented in Fig. In the situation depicted in Fig. In the dissection depicted in Figs. The suspensory ligament originates on the subsymphyseal angle and attaches to the dorsal aspect of the penis, deep to the fundiform ligament , 19.It mainly consists of two laminas that fuse anteriorly in a unique border, creating the appearance of a triangular pyramid , 17. TheFigure In Fig. In Fig. Figure After the complete removal of the two ligaments and of the deep fascia of the penis, the dorsal neurovascular bundle becomes apparent in Fig. The issue of maintaining the penile body in position whilst also keeping it on the midline during penile aesthetic surgeries is solved in a complex way. Both the fundiform and the suspensory ligaments connect the penis to the pelvic wall. The terminal fibers of these ligaments surround the penile body in a hammock-like manner and create the presymphyseal curvature of the penis. However, the median bundle fibers of the suspensory ligament that originate on the inferior aspect of the symphyseal arch end directly on the deep penile fascia and keep the penile body on the median line. The possibility of damaging either the external pudendal vessels (located at the base of the fundiform ligament) or the dorsal neurovascular bundle of the penis (located at the base of the suspensory ligament) represents a real surgical risk in ligamentolysis.The space between the penis and the symphyseal arch is closed from superficial to deep by the divergent bundles of the fundiform ligament, the lateral blades of the suspensory ligament and the median bundle of the suspensory ligament. This space is also limited by the connective fibers system that early anatomists called the Luschka ligament .It is obvious that if the suspensory apparatus is sectioned, this morphofunctional unit located between the penis and the pelvic wall loses its function and the movements of the penile body no longer faithfully follow the movements of the pelvis. Furthermore, this can also result in changes in the anterior curvature of the penis.Regarding penile augmentation following the sectioning of the suspensory apparatus, we state that the relative penile elongation is the result of the decrease of the penile presymphyseal curvature. The possible aesthetic benefit is drastically impaired by the dynamic functional disadvantage, as mentioned above. The main surgical risk is the injury of the external pudendal vessels or of the dorsal vascular bundle of the penis, in which case, a local hematoma may form and subsequently migrate inside the pelvis, through the space between the dorsal aspect of the penis and the symphyseal arch.


Early-life animal exposure has been associated with both protective and harmful effects on asthma and allergic disease. We aimed to explore factors that may modify associations of early-life animal exposure with asthma and allergic disease, so as to better understand these differences in findings.We used data from ≤84 478 children from the Danish National Birth Cohort recruited during pregnancy between 1996 and 2002, and linked registry data up to the child’s 13th birthday. Adjusted Cox models were used to examine associations of early-life cat, dog, rabbit, rodent, bird and livestock exposure with atopic dermatitis, asthma and allergic rhinoconjunctivitis overall, and by source of exposure (domestic or occupation), parental history of asthma or allergy, maternal education level and timing of exposure.Overall, associations between animal exposure and the three outcomes of interest were weak. However, dog exposure was associated with marginally lower risk of atopic dermatitis and asthma , whereas prenatal domestic bird exposure was associated with slightly increased risk of asthma . Source of exposure, parental history of asthma or allergy and timing of exposure modified associations. Early-life animal exposure did not appear to increase the risk of allergic rhinoconjunctivitis .The overall weak associations observed between animal exposure and atopic dermatitis, asthma and allergic rhinoconjunctivitis were modified by type of animal, source of exposure, parental history of asthma or allergy and timing of exposure, suggesting that these factors should be considered when assessing the risks associated with early-life animal exposure. Key MessagesWe used data from a large prospective birth cohort to examine associations of early-life animal exposure with childhood atopic dermatitis, asthma and allergic rhinoconjunctivitis, including potential modifying factors.Overall, associations between animal exposure and the three outcomes of interest were weak.Early-life dog exposure was associated with marginally lower risk of atopic dermatitis and asthma, whilst early-life bird exposure was associated with marginally increased risk of asthma.There was no evidence of early-life animal exposure increasing the risk of allergic rhinoconjunctivitis.Source of exposure, parental history of asthma or allergy and timing of exposure were observed to modify associations, suggesting that these factors should be considered when assessing the risks associated with early-life animal exposure.Atopic dermatitis (AD), asthma and allergic rhinoconjunctivitis (AR) are complex, multifactorial diseases that commonly co-exist as multiple morbidities,,Studies have shown that exposure to animals can increase the diversity of the gut microbiomeAlthough most studies have focused on the risks associated with cats and dogs or ‘furry pets’ as a single entity, it is also likely that associated risks will vary depending on the type of animal. For example, animals such as rabbits, rodents and birds are less popular as pets ,The aim of the current study was to comprehensively examine associations of early-life animal exposure with later risk of AD, asthma and AR, including potential modifying factors, in a large prospective birth cohort. We specifically examine: (i) overall associations between prenatal species-specific animal exposure and risk of AD, asthma and AR; (ii) whether associations vary by source of exposure; (iii) the possibility of reverse causation; and (iv) the relative influence of prenatal vs early-childhood exposure.The Danish National Birth Cohort (DNBC) is a nationwide birth cohort study that was established between 1996 and 2002.IJE online).The current study includes all live-born singleton children participating in the DNBC with information on maternal animal exposure during pregnancy and relevant covariates . ParticiIJE online).,Children with AD, asthma and AR were identified using linked hospital episode (inpatient and ambulatory) and/or prescription data held in the Danish National Patient RegisterIJE online).In sensitivity analyses, we used the following outcome definitions based on parental-reported symptoms and/or disease outcomes obtained from questionnaires: AD derived from a validated algorithm created for DNBC at 18 months;IJE online).Information on mothers’ animal exposure was obtained during the first prenatal telephone interview, at ∼16 weeks’ gestation, where mothers were asked about their domestic (pet), occupational and farm-related contact with animals, including type of animal (questions are provided in These data were used to create six binary variables (yes/no) capturing combined domestic, occupational or farm-related prenatal exposure to dogs, cats, rabbits, rodents, birds and livestock. Six categorical variables were also created detailing source of exposure for each animal group .IJE online). These data were combined with information on prenatal animal exposure to create categorical variables relating to the timing of cat, dog, rabbit, rodent and bird exposure .Information on the index child’s exposure to animals in the first 2 years of life was obtained during the 18-month telephone interview, in which mothers were asked to name any animals the child was in contact with (detailed in IJE online). Potential confounders included: (i) maternal asthma (yes/no); (ii) maternal inhalant allergy (yes/no); (iii) paternal asthma (yes/no); (iv) paternal allergy (yes/no); (v) maternal education (low/medium/high); (vi) quartiles of equivalized disposable household income the year prior to the child’s birth; (vii) maternal age at birth; (viii) number of children living in the home (0/1/≥2); (ix) household crowding (≤0.5/>0.5–1/>1 person per room); (x) smoking during pregnancy (yes/no); (xi) living in Copenhagen at birth (yes/no); (xii) sex.Potential confounders were identified based on the literature and the causal model represented in a directed acyclic graph .In sensitivity analyses, we explored the sensitivity of findings to the applied definition of AD, asthma and AR. For these analyses, questionnaire-derived and register-based outcomes were analysed using logistic regression, restricted to the same children . Interestingly, any protective effect of animal exposure on asthma or AR was negated if the child developed AD (IJE online). In some instances risks were elevated, notably for associations of early-life rabbit or livestock exposure with asthma  (IJE online).Overall, effect estimates were relatively small for all prenatal animal exposures . PrenataIJE online).In sensitivity analyses, results were largely consistent for reported and register-based outcomes  exposures , which iIJE online).Since evidence suggests that families with asthma or allergies may avoid petsPinteraction > 0.10) (IJE online).We explored the potential for reverse causation further by examining whether maternal education modified associations. Knowledge acquired through education may affect receptiveness to medical advice,n = 61 290, In a subset of children with information on both prenatal and early-childhood animal exposure (IJE online) and also the large proportion of farm and occupationally related prenatal bird exposures (For rabbits, rodents and birds, the majority of exposures occurred prenatally only . This poxposures . The infxposures .In this study of ≤84 537 children from the DNBC, we used detailed information on early-life animal exposure, including type of animal, source and timing of exposure, and linked population-based register data to examine how early-life animal exposure influences the risk of AD, asthma and AR. Overall, effect estimates for animal exposure were relatively small. We did, however, observe evidence that early-life exposure to dogs may offer some slight protection against AD and asthma, but that prenatal exposure to birds may slightly increase the risk of asthma. We also observed evidence that source of exposure, parental history of asthma or allergy and timing of exposure may modify associations. Associations with AR were weak but did not indicate any harmful effect of early-life animal exposure.The strengths of this study include its large size, prospective design and detailed information on prenatal animal exposures, encompassing domestic, occupational and farm-related exposures, as well as exposure to animals other than cats and dogs, which have been less studied. We based our outcome measures on linked hospital episode and/or disease-specific prescription data, which allowed complete follow-up, thereby minimizing selection bias due to non-participation. Using registry-based outcomes likely increased the specificity of our outcome measures,,However, our study also has several limitations. First, our register-based AR outcome will lack sensitivity to identify milder cases of the disease that can be treated using over-the-counter medication. This may explain the small effect estimates observed for AR. Similarly, due to the lack of specificity of medication used to treat AD, we based our definition of AD solely on ICD-10 codes and will have missed milder cases of AD. Nonetheless, effect estimates for AD were similar to those obtained using caregiver-reported symptoms in sensitivity analyses. We also did not consider different disease phenotypes in our analyses, which may have different environmental associations.,,,,,,,,The literature regarding the influence of early-life animal exposure on later risk of asthma and allergic disease is conflicting.The literature regarding the effects of early-life exposure to rabbits, rodents and birds on the risk of asthma and allergic disease is sparser. A meta-analysis of European birth cohort data found no association between rodent or bird exposure and school-age asthma or AR,The tendency we observed for animal exposure to be associated with lower rates of AD, asthma and AR among children with parental history of asthma or allergy compared with children without could be consistent with reverse causation, namely the avoidance of pets by families with pet allergies,In conclusion, whereas overall our findings do not indicate a strong role for early-life animal exposure in the development of AD and asthma, they do point towards early-life dog exposure offering some slight protection against AD and asthma, and bird exposure increasing the risk of asthma. Source of exposure, parental history of asthma or allergy and timing of exposure may also modify risks. Our results were more consistent for AR and did not suggest an increased risk with early-life animal exposure.The DNBC is approved by the Danish Data Protection Agency and the Committee on Health Research Ethics. The DNBC participants were enrolled by informed consent. This study received approval from University of Copenhagen Faculty of Health and Medical Sciences under case number 514–0538/20–3000.dyad040_Supplementary_DataClick here for additional data file.


The COVID-19 pandemic has had an impact on the emergency department (ED). Door-to-needle time (DNT) could be prolonged for intravenous thrombolysis (IVT) treatment. We aimed to investigate the impact of two COVID-19 pandemics on the workflow of IVT in our neurovascular ED.We performed a retrospective analysis of patients who received IVT treatment in the neurovascular ED of Beijing Tiantan Hospital, Beijing, from January 20, 2020, to October 30, 2020, covering two COVID-19 pandemics in China. The time-based performances of IVT treatment including onset-to-arrival time, arrival-to-CT time, CT-to-needle time, door-to-needle time, and onset-to-needle time were recorded. Data on clinical characteristics and imaging information were also collected.n = 95). Longer DNT  interval delays were observed during the two pandemics (p = .016). More patients admitted during the two pandemics had an ‘unknown’ subtype . The percentage of the cardiac embolism subtype was higher during the Wuhan pandemic (20.0%) than during other periods. The median admission NIHSS score increased during the Wuhan pandemic and the Beijing pandemic .Four hundred forty patients that received IVT were enrolled in this study. The number of patients admitted to our neurovascular ED began to decrease in December 2019 and was the lowest in April 2020 (The number of patients who received IVT decreased during the Wuhan pandemic. Higher admission NIHSS scores and prolonged DNT intervals were also observed during the Wuhan pandemic and the Beijing pandemic. The COVID-19 pandemic has had a great impact on global medical systems including the neurology department and other internal medicine departments [rd among the top 10 causes of disability-adjusted life-years in 2019 [Stroke ranked the 3 in 2019 , and neu in 2019 . During  in 2019  due to t in 2019 –9. How tWe retrospectively analyzed the data from our stroke center before, during and after the two COVID-19 pandemics in China to investigate the impact of the COVID-19 pandemic on IVT treatment to help improve the workflow of IVT treatment in neurovascular emergencies.We performed a retrospective analysis of patients who received IVT treatment in the neurovascular emergency department of Beijing Tiantan Hospital, Beijing, from January 20, 2020, to October 30, 2020, covering two COVID-19 pandemics in China . Pandemic response measures, including lockdowns, were triggered in Wuhan in January 2020, and it was the first COVID-19 pandemic in China. Xinfadi is a large market of vegetables and fruit near our stroke center at Beijing Tiantan Hospital in Beijing. Xinfadi experienced a COVID-19 pandemic in June 2020, and the emergency rooms of Beijing Tiantan Hospital, including its neurovascular emergency department, were influenced. Patients who received IVT treatment from January 2019 to October 2019 were included as a reference. Based on the periods of the two pandemics, we divided our participants into 5 groups: pre-COVID-19 group, from January 1, 2019 to October 30, 2019; Wuhan pandemic group, from January 20, 2020 to April 26, 2020; post-Wuhan-pandemic group, from April 27, 2020 to June 10, 2020; Beijing pandemic group, from June 11, 2020 to July 21, 2020; and post-Beijing-pandemic group, from July 22, 2020 to October 30, 2020.The study was conducted in accordance with the Declaration of Helsinki. The fully deidentified data on the patients enrolled in the current study and its retrospective study design enabled this study to be conducted under a waiver of informed consent by the local institutional review board. The study was approved by the ethics committee of Beijing Tiantan Hospital (No.: KY2015-001–01). This manuscript was based on the Strengthening the Reporting of Observational Studies in Epidemiology statement to report the results of the current study.All patients who received IVT treatment were consecutively enrolled. The inclusion criteria were as follows: 1) diagnosed with acute ischemic stroke in our neurovascular emergency department; 2) received IVT with alteplase (0.9 mg/kg) within 4.5 h from symptoms onset; and 3) had a cranial CT/MR scan within 24 h of IVT treatment.The demographic information among the enrolled patients included age, sex, medical history, alcohol and tobacco intake and medication history. Onset-to-arrival time , arrival-to-CT time , CT-to-needle time (defined as time of the first CT scan to time of the IVT initiation), door-to-needle time  and onset-to-needle time (from stroke onset to time of the IVT initiation) were recorded to evaluate the influence of the COVID-19 pandemic on the workflow of IVT treatment in our neurovascular emergency department. Patients confirmed to have large vessel occlusion of the anterior circulation were evaluated if they were eligible for bridging mechanical thrombectomy (MT) therapy. Stroke severity was measured by the NIHSS score . The TriP value < 0.05 was considered statistically significant.Continuous variables are expressed as the mean ± SD for normally distributed data and median (interquartile range) for nonnormally distributed data. Categorical variables are expressed as numbers (percentage). Normally distributed data were compared using one-way ANOVA, and nonnormally distributed data were compared using the Kruskal–Wallis test. Categorical variables were compared using the χ2 test, as appropriate. All statistical analyses were performed with SPSS 26.0. A p = 0.072). The percentages of males during the Wuhan and Beijing pandemics were 70.7% and 82.9%, respectively   and IVT bridging MT (n = 11) . However, the percentage of DNT time ≤ 60 min did not decrease significantly during the two pandemics (p = 0.146). Compared with the CT-to-tPA time, the arrival-to-CT time was prolonged during the two pandemics .Longer DNT interval delays were observed during the two pandemics . The percentage of the CE subtype during the Wuhan pandemic was higher than that during the other periods (20.0%). The median admission NIHSS score during the Wuhan pandemic increased compared with that during the pre-COVID-19 period . The Beijing pandemic had a higher median admission NIHSS score than the Wuhan and Beijing pandemics . While this difference remained after the intravenous tPA drip finished (p = 0.013), the NIHSS score was similar at 2 h (p = 0.411) and 24 h after IVT (p = 0.275). Lower percentages of minor stroke (NIHSS score ≤ 3) were observed during the two pandemics . Patients who received IVT treatment during the Wuhan pandemic had the highest percentage of sICH of the SITS classification, (7.3%) and patients who received IVT treatment after the Beijing pandemic had the highest percentage of sICH of the ECASS II classification (11.7%).For the TOAST subtype of ischemic stroke, more patients admitted during the two pandemics had stroke of undetermined etiology . However, during the Beijing pandemic, the percentage of CE subtypes was the lowest (5.71%). Many patients receiving IVT rejected admission to neurology inpatient wards to complete further examinations on the TOAST subtype during the Beijing pandemic. Some patients with the CE subtype might be classified into the unknown subtype (30%). During the Wuhan pandemic, four stroke centers from Wuhan also admitted more patients with the CE subtype and an elevated percentage of stroke of undetermined etiology, which is consistent with our study . A largeAs the global pandemic of COVID-19 shows no tendency to cease, stroke centers are faced with its impact on neurovascular emergencies, including prolonged DNT time and a shortage of stroke team members. Studies on the workflow of neurovascular emergencies are warranted to minimize the DNT delay and door-to-puncture time to achieve rapid recanalization and more favorable functional outcomes . Most ofSeveral limitations have to be admitted in our study. The retrospective and single-center study design may introduce selection bias. However, as the Chinese government transferred many doctors to fever clinics during the COVID-19 pandemics, stroke emergency and neurology inpatient wards lacked doctors to conduct a prospective cohort or registry study that included hospitals from different regions. Second, the sample size of our study may be small. However, our single-center, retrospective study did not depend on a large study sample, and our study provided a larger sample than another retrospective study from China . Third, Our study found that the number of patients who received IVT decreased during the Wuhan pandemic. Higher admission NIHSS scores and prolonged DNT intervals were also observed during the Wuhan pandemic and the Beijing pandemic.